Provider Demographics
NPI:1457711582
Name:BACK TO BASICS CHIROPRACTIC., PLLC
Entity Type:Organization
Organization Name:BACK TO BASICS CHIROPRACTIC., PLLC
Other - Org Name:CARLENE A BOLEN DC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-251-8800
Mailing Address - Street 1:845 N ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2242
Mailing Address - Country:US
Mailing Address - Phone:918-251-8800
Mailing Address - Fax:918-251-8802
Practice Address - Street 1:845 N ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2242
Practice Address - Country:US
Practice Address - Phone:918-251-8800
Practice Address - Fax:918-251-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3532111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1083650295OtherINDIVIDUEAL NPI TYPE 1
OK241414218Medicare PIN